DEPARTMENT OF PUBLIC HEALTH HOSPITAL &R
TRIVENI
DENTISTRY
INSTITUTE OF SCIENCES,
RESEARCH CENTRE,DENTAL
BILASPUR, CHHATTISGAR
Student's Name:
Date
OPNO.
Patient's Name
Age
Sex:
Date and place of Birth
Education Occupation:
Total income of
family
No. of family
members
Percapita income per month
Address
Contact No.
Chief complaint
I. History of present illness:
Medical History
V Dental History
P A R
N. Family History
a. Siblings
Number Age
Has any
family member suffered from a similar problem ?
Do you
know any illnesses that run in your family?
b. Marital Status Married Unmarried
C. Children (if any) Number
VI. Age
Personal History
/a. Personal Habits:
Type Number Frequency Duration
1. Smokingg
2. Smokeless tobacco
(with/without pan chewing)
3. Pan Chewing
G (with/without tobacco)
4. Alcoholism
b.
OK Habits related to oral
Mouth Thumb
cavity:
Tongue Bruxism
Breathing Sucking Thrusting Lip/nail/Pencil/Bitting
Frequency:
Duration
c) Oral Hygiene Practices:
1.Type of cleaning:
Specify if any other)Toothbrush Finger
Finger Twi
Twigg Others
2.Method of Cleaning:
3.Material used: Vertical Horizontal Circular
Toothpaste Tooth powder
Sand Charcoal
4.Frequency of Brick powder Any other U
cleaning: Once Twice
S.Time of brushing: Before
meals
Twice Thrice
6. After meals
Frequency of changing the toothbrush;
7.Use of other oral
hygiene aids: FlossingInterdentalaids
Oral Mouth rinse Others
d) Dietary habits:
1. Source of water: Bore Well Others
2.Vegetarian Mixed
3. Dietary chart:
Staple Diet:
Time Item Sugar Exposure
456
Sugar consumption (per day)
Type of Carbohydrate:
Frequency: Once Twice Thrice Fourtimes
Please specify if more:
Time of intake: With meals In-between meals
Form and consistency Solid Liquid
Sticky Non stick
VIL
General Examination:
a) Gait
b)
Posture
Built:
VIll. Local Examination:
a)
Extra Oral:
1.
Symmetry:
2 Profle:
3. T.MJ.:
Lymph nodes
5. Lips
b) Intra Oral:
1. Soft Tissue
Labial mucosa:
Bucca Mucosa
Palate
Tongue
Floor of mouth
Alveolar mucosa:
Gingiva:
2 Hard tissue:
Type of dentition:Deciduous MixedPermanent
Teethpresent
Teeth absent and reason for loss:
Dental caries:
Non Cavitated:
Cavitated
Cavitated with pulp exposure:
Root stumps:
Filledteeth:
Any prosthesis: Crown
Bridge
RPD/Implant
Wasting disease a. Generalized b. Localized (mention tooth)
Attrition
B. Abrasion
Erosion
chamelhypoplasia: Generalised Localised
Dental Fluorosis Yes No
Supernumerary teeth:
Malocclusion:
Fractured/Non vital tooth:
Stains
Extrinsic Intrinsic
Any other
anomaly please specify:
Periodontal Status
Gunginitis:
Generalised Localised (mention
tooth)
Gingival recession:
Periodontal pocket:
Mobility of teeth:
A. Oral Hygiene Status
Dental deposit:
Plaque Stains Calculus
Good Fair
Poor
INDEX
IX. Provisional diagnosis:
Investigation:
XI Diagnosis:
Xll. TreatmentPlan:
PATIENT SIGNATURE
XIll. Workdone:
Date Work done Remarks
